Tuesday, October 11, 2005

A magazine article

I have written an article for a friend of mine, who is president of the Luxembourg Society of Psychologists. It will appear in their quarterly magazine.

Why do people stutter?

This question has been and is puzzling people who stutter, people who hear them stutter but speak fluently themselves without even thinking how they speak, and the health professionals who try to help alike. Scientific and folk theories have been floating around through the centuries. Aristotle, who stuttered himself, thought of a malfunctioning tongue. Or, the people who stutter are just extra nervous when speaking, because everyone experiences stuttering in extreme situations. Psychoanalysts see clear underlying psychological conflicts arising from childhood, or suggest neurosis: people who stutter might subconsciously derive gains. Asking people who stutter does not help much either. They generally have no clue why they stutter, but they can often predict when they will stutter, but not always. Treating stuttering has again been a true source of ingenuity. Some German surgeons advocated cutting out a part of the tongue. Another treatment involved not talking for 5 weeks. Yet other treatments include talking in rhythmic manner, antidepressants, or searching why you subconsciously want to stutter.

Stuttering is a puzzling disorder. People who stutter report that they are unable to say certain words even though they know exactly what they want to say, but they just cannot say them. Stuttered speech involves hesitations, blocks, fillers like ehhhh, word substitution, avoidance of eye contact, face grimaces and more. Paradoxically, people who stutter are able to speak completely fluent under certain circumstances, e.g. talking alone, singing, speaking with a foreign accent, or in rhythm. On good days, they can be fluent, and on bad days they stutter on every second word. Sometimes they are stuttering mildly, but suddenly have a block and become much more disfluent, or the other way around. Some stutter openly and do not avoid speaking situations. Others stutter mildly, but their life is filled with fear and anxiety and centres around avoiding speaking situations whenever possible. They switch words around, get other people to make important phone calls, forget the answer even though they know the answer, order water rather than b-b-beer, and love emails. They look and behave like everyone else, not less intelligent, more nervous, or more psychologically disturbed. Stuttering is not a language problem, because people who stutter do not have language problems. It does not really seem to be a speech problem either, because people who stutter have the ability in some circumstances to speak completely fluently.

There are a few established facts about stuttering. Stuttering is really only a symptom of a disorder, persistent developmental stuttering or PDS. It is persistent, because it is not a temporary inability to speak fluently but persists from early childhood onwards. It is developmental, because it starts in early childhood when the child develops his or her speech capabilities. At around the age of 3, some children go through a period of disfluency. Most children recover naturally to become fluent speakers, but about 20% do not and their stuttering persists. They quickly develop secondary symptoms and suffer psychologically and socially. There are also forms of acquired stuttering, which is due to a stroke or neurological incident in late adulthood. About 1% of a population has PDS. There are about three to four times more men with PDS than women. Occurrence of PDS often runs in families, and there are even extended families in Cameroon and Pakistan where most family members stutter. There is much more to PDS than overt stuttering. The analogy of the iceberg is often used to suggest that much suffering is hidden underneath unknown to the listener. Paradoxically, the bigger handicap arising from PDS is very often the psychological and social avoidance and suffering rather than the stuttering itself. Stuttering tends to increase when the workload of the brain increases during stress and emotionally or grammatically difficult speech.

There have been many treatment approaches, but none can be considered a cure. However, the consensus is that someone having from PDS can significantly reduce the psychological and social suffering and become an effective, if not always a fluent, speaker. Unfortunately, relapses in fluency are common occurrence, and lasting success requires a lot of patience and efforts. Often, people make sensational improvements and are shown on TV, but many experience a relapse when the camera is switched off. The effect is rather similar to a diet: the difficulty is not to loose weight, but not to regain weight within a year! It also depends on the individual, and whether their stuttering is mild or more severe, and how much avoidance behaviour exists. There are two main schools of thoughts to make people more fluent: teach them speech techniques that insure fluent speech or teach them how to stutter more mildly. In fluency shaping, the patients learn how to speak more fluently by using techniques like gentle onset, slowed down speech, connecting syllables, and more. As they speak fluently, they do not have secondary symptoms and psychological and social issues should dissolve. In stuttering modification, the patients learn to deal with their stuttering to consciously allow stuttering but with less tension and reduction of secondary symptoms. Both approaches can be effective, and often have similar results. Another approach is to mainly work on psychological and social issues. This can be effective for very mild stuttering (or patients with psychological issues), and helpful for more severe stuttering in reducing the significant handicap that psychological and social effects brings about, but rarely does it bring fluency. All three approaches can happen within self-help groups, intensive stuttering therapy programs, or with a local speech and language therapist. However, local speech and language therapists often have little experience with treating stuttering and resort to their own creativity to treat. Therefore, the author strongly recommends to only work with a therapist who has specialised in PDS. Finally, treatment with drugs is gaining grounds. Several drugs seem to reduce stuttering but with some side effects. Clinical studies are underway.

Why do people stutter? Stuttering is a highly complex disorder on a social, psychological, behavioural and neurological level with all levels interacting with each other. Despite a century long effort, it is fair to say that no-one really understands the underlying mechanism of stuttering nor does anyone have a theory of stuttering that can be and has been verified. Better therapy has mostly come from trial and error rather than a fundamental understanding of the disorder. The problem lies deeper than overt speech production, and probably involves language, speech planning and execution inside the brain. Unfortunately, until recently, there had been no useful tools available to study the living brain. But, it is now possible to look directly at the living brain in detail and a revolution is currently under way. The emerging consensus is that the brains of people with PDS show clear activation and structural differences to the normal population. Firstly, at rest, the activation level of the PDS brain compared to control subjects are the same. Secondly, there are clear differences during speech in the activation levels in various regions. Thirdly, in comparison, the speech-dominant left brain is less activated and the right brain is more activated. Fourthly, even during fluent speech of people with PDS, there are differences in activation. Moreover, several groups now claim that the left brain also shows a structural abnormality (which would fit with the different activation level). This is promising news, but theory building becomes important now. The experimental results need to be separated between causes and effects. On another front, genetics research has signalled out chromosomes (packages of genes) that are directly correlated with occurrence of PDS. Stuttering tends to run in families to the same degree that for example increased risk of breast cancer or heart attacks runs in families.

What is the most likely mechanism for stuttering? The best guess is that something goes wrong on the neurological level at around an age of three, at the time when the language and speech region need to produce grammatically correct sentences. There might exist a structural weakness, most likely influenced by genetic predisposition or a neurological incident (like a blow to the head or an illness). Then the young brain must cope by recruiting other brain regions, most likely in the right brain. This compensatory system corrects the deficiencies, but is more sensitive to interference. This may explain why people with PDS can be perfectly fluent and will stutter when the compensatory region suffers from work overload during stress and emotionally or grammatically difficult speech. Childhood disfluency evolves by learning secondary symptoms like blocks, reduced auditory feedback, fillers, avoidance and fears. The secondary symptoms reinforce and make stuttering much worse, which in turn creates very complex and very individual psychological reactions and social behaviour, which in turn maked stuttering a serious handicap.

The next years are going to be exciting as our understanding of PDS will get better. But, there is no doubt in the author's mind that a better understanding of stuttering on a fundamental level is our best possible way forward towards more efficient therapy with fewer relapses. Every breakthrough in any field has been marred by setbacks, errors and delays. The key to success is to never ever give up!

8 comments:

Excellent article! It represents a nice compact overall view on the subject. Highly understandable and interesting to read. Hopefully some luxembourgish psychologists might consequently spare some of their stuttering patients from their own absurd theories... ;-)